Role of perineal bulbourethral sling implant and neurosacral modulation for the treatment of urinary incontinence after radical prostatectomy. Our experience
Urinary incontinence following radical prostatectomy is mainly a consequence of external sphincter impairment. However a concomitant urge component can be present and best assessed only after an appropriate “restitutio ad integrum” of the sphincter function. Hence, patients, who have undergone prostatectomy, with a residual urinary incontinence following the implant of perineal bulbourethral sling, represent the experimental model available in clinical practice. The partial effect achieved after this surgery could be due to the presence of minor or latent functional bladder dysfunction, which becomes dominant after the surgical correction of the sphincter defect. The rationale of this analysis is the mid term evaluation of the efficacy of sacral neuromodulation, as treatment for urge urinary incontinence in patients who have undergone a perineal bulbourethral sling implant after prostatectomy.
Materials and Methods
From January 2010 to December 2011, 77 patients referred to our center for post radical prostatectomy incontinence. Patients were routinely submitted to office cystoscopy and urodynamic assessment. Cases characterized by partial intrinsic sphincter deficiency (defined as functional length less than 2 cm, RLPP test < 40 cm H20, MUCP < 45 cm) and mild incontinence (pad test lower and upper limits respectively 20 and 500 mL) underwent transobturatoy tensive perineal tape placement . In all 49 patients had surgery. Twenty-two of them regained continence (no or one pad per day), the remaining 27, who declared a partial or no improvement were submitted again to urodynamic evaluation. Twenty-five cases with a reduced bladder compliance were candidates to sacral neuromodulation. Twenty-two were implanted with sacral neuromodulator (InterStim – Medtronic)  which implies two distinct procedures: 1) a temporary implant to test efficacy and then, after 2 – 4 weeks, 2) the permanent implant. The procedures were performed under combination of x-ray and electrical stimulation guidance in local anesthesia. One temporary implant was removed for infection, one for malfunction. Patients were followed up with interview, physical examination, ICIQ-SF questionnaires and pad test before and post implantation, at 3 months and then yearly. Two patients died within 2 years after the implant, one for disease and one for unrelated causes whereas 18 had at least 2 year follow and were object of the report. ICIQ-SF and pad test findings pre and post implant were subjected to a Student’s T –test for paired samples for analysis of statistical significance. The test was two tailed for ICIQ-SF assessment (in the assumption of eventual worsening of quality of life after implant) and one tailed for the pad test (in the assumption that nothing changes in the worst scenario after implant). Significance level was fixed at 0.05.
Two years after implant overall 12/18 (66%) had a complete or partial response to the treatment. Ten out of 18 (55%) declared to be satisfied and happy to have decided to be treated. Four patients were completely continent (no pad), four quasi-continent (1 pad), four improved of at least 50% (namely halved the number of pads used before the implant) and five improved of at less than 50% or not responded at all respect to pre implant assessment. The pads’ number was reduced significantly from 4.3 ± 2.3 to 1.9 ± 1.6 (p<0.001). The ICIQ-SF score decreased significantly from 16.3 ± 3 a 10.9 ± 4.5 (p<0.001).
Return to continence in about half of patients treated shows the potential effectiveness of sacral neuromodulation as treatment of the urge incontinence component post-radical prostatectomy after sling implant. Moreover, satisfaction rate, expressed by a direct and precise question to the patient was significantly high considering the general dissatisfaction underlying post prostatectomy continence and a “failed” sling implant. The impression obtained by interviewing the patients is substantiated by an objective and statistically significant improvement in ICIQ-SF score and number of pads used. We reported ours results over a period of 2 years thus suggesting the achievements are definitive. Moreover benefits have been reached with a mini-invasive one day surgery procedure performed in local anesthesia with the guidance of electrical stimulation and fluorescence which is not undermined by significant complications
In this series of selected patients, the residual urinary incontinence was treated effectively with sacral neuromodulation when the urodynamic evaluation, performed after the implant of the sling perineal bulb, showed a reduction in bladder compliance. The 2 year follow up is not yet enough to consider definitively stable the results achieved even if it will likely remain unchanged. Most important the procedure is safe, mini invasive and performed in local anesthesia. Further studies are needed to validate the technique and its results. By the way our report should encourage centers specialized in male incontinence treatment to perform dedicated clinical trials.
1) Ceresoli A, Guarneri A, El Rahman DA, Cazzaniga A, Macola GG. New perineal tensive transobturator tape (T-TOT) for postprostatectomy urinary incontinence. Arch Ital Urol Androl. 2010 Dec;82(4):154-8.
2) Spinelli M, Giardiello G, Gerber M, Arduini A, van den Hombergh U, Malaguti S. New sacral neuromodulation lead for percutaneous implantation using local anesthesia: description and first experience. J Urol. 2003 Nov;170(5):1905-7.Argomenti: incontinenza